Claims workbench/CLM-2026-010641
Professional claim · CMS-1500 · EDI 837P

CLM-2026-010641

Lakeside Digestive Health Center, Gastroenterology. Service 2026-06-09 at office (POS 11). Received 2026-07-18.

Approved
Billed
$290.00
1 line
Allowed
$179.80
contract rate applied
Plan pays
$139.80
approved
Member owes
$40.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Dennis Hansen
Member ID
UHC-38793-05
Date of birth
1940-05-06
Identity
Verified4 records, confidence 0.98
Claim record
CLMCLM-420856
Relationship
Child, Phoenix, AZ

Coverage and accumulators

Found by member ID

Plan
MEDICARE-ADV-B MA group GRP-0968
Coverage period
2022-07-01 to present
Deductible
$844.58 of $1,000.0084%
Out-of-pocket maximum
$1,492.37 of $3,000.0050%
Copays
office $40.00, specialist $40.00, emergency $350.00
Physical therapy visits
6 of 20 used

Provider

Billing and rendering

Billing provider
Lakeside Digestive Health Center
Gastroenterology · taxonomy 207RG0100X
NPI
5154884873
Network
In network
Rendering NPI
4255062968
Location
Denver, CO · TIN 37-4223782
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199214Office visit, established patient, moderate complexity—11$290.00$179.80$40.00$139.80Paid
Totals$290.00$179.80$40.00$139.80
Diagnoses (ICD-10-CM)
  • 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
Claim header
Patient account
PA-540305
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 0 needing attention

CheckResultCodeDetail
Member identityPassAttached to MBR-004618 (verified, link confidence 0.98).
EligibilityPassActive on 2026-06-09: MEDICARE-ADV-B (MA), effective 2022-07-01.
Timely filingPassReceived 39 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Lakeside Digestive Health Center (5154884873).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Lakeside Digestive Health Center2026-06-09 18:02

    Established patient presents with encounter for screening for malignant neoplasm of colon; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Explanation of benefits

What the member will see

Amount billed
$290.00
Plan discount
$110.20
contracted rate
Plan paid
$139.80
You may owe
$40.00
copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineApproved2026-10-22 12:44
    Clean claim.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

Clean claim: the rules engine approved it, so no AI review was needed.

Examiner decision

Approved by Claims rules engine; an examiner may still override

Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queueMember identity